Treatment of Ankylosing Spondylitis
Start all patients with active ankylosing spondylitis on NSAIDs as first-line therapy combined with physical therapy, and escalate to TNF inhibitors if disease activity remains high despite adequate NSAID trials. 1
First-Line Treatment Approach
NSAIDs (Strongly Recommended)
- NSAIDs are the cornerstone pharmacological treatment for patients with active AS presenting with pain and stiffness 1, 2
- Continuous NSAID therapy is preferred over on-demand use for patients with persistent, active symptomatic disease 2
- Trial at least two different NSAIDs at maximum tolerated doses for at least 3 months each before declaring NSAID failure 2
- For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 2
Common Pitfall: Inadequate NSAID trials before escalating therapy—ensure proper dosing and duration before moving to biologics 2
Physical Therapy (Strongly Recommended)
- Physical therapy must be initiated immediately alongside pharmacological treatment as it is a cornerstone of AS management 1, 2
- Both individual and group physical therapy are effective, with group therapy showing superior patient global assessment outcomes 2
- Regular exercise programs should be continued throughout the disease course 2
Second-Line Treatment: TNF Inhibitors
When to Escalate
- Initiate TNF inhibitor therapy when disease activity remains persistently high (BASDAI >4) despite adequate trials of at least two NSAIDs for at least 3 months 1, 2
- This represents a strong recommendation based on Level Ib evidence 1
TNF Inhibitor Selection
- No particular TNF inhibitor is preferred for most patients with AS—infliximab, etanercept, and adalimumab are all appropriate choices 1
- Exception: For patients with concomitant inflammatory bowel disease, strongly prefer TNF inhibitor monoclonal antibodies (infliximab or adalimumab) over etanercept 1, 3
- For patients with recurrent iritis, similarly prefer monoclonal antibodies over etanercept 1
FDA-Approved TNF Inhibitors
- Adalimumab: 40 mg subcutaneously every other week 3
- Etanercept: 50 mg subcutaneously weekly 4
- Both agents are indicated for reducing signs and symptoms in adult patients with active AS 3, 4
Important Safety Consideration: All TNF inhibitors carry black box warnings for serious infections (including tuberculosis reactivation) and malignancies—test for latent TB before initiating therapy 3, 4
Treatments to Avoid
Systemic Glucocorticoids (Strong Recommendation Against)
- Do not use systemic corticosteroids for axial disease in AS due to lack of efficacy evidence and significant side effect profile 1, 2
- Local corticosteroid injections may be considered for peripheral arthritis or enthesitis only 2
Conventional DMARDs
- Sulfasalazine and methotrexate lack convincing evidence for axial disease in AS 2
- These agents should not be used as substitutes for TNF inhibitors in NSAID-refractory axial disease 2
Adjunctive Therapies
Analgesics
- Paracetamol and opioids may be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 2
- These are supplementary measures, not replacements for anti-inflammatory therapy 2
Concomitant Medications
- Methotrexate, glucocorticoids (for peripheral manifestations only), and analgesics may be continued during TNF inhibitor therapy if clinically necessary 3, 4
Disease Monitoring
- Monitor disease activity using patient history, clinical parameters (including BASDAI score), inflammatory markers (CRP, ESR), and imaging as clinically indicated 2
- Assess pain levels, functional status, structural damage progression, and comorbidities at regular intervals 2
Surgical Intervention
- For patients with advanced hip arthritis, total hip arthroplasty is strongly recommended over conservative management 1
Critical Pitfall to Avoid: Overreliance on imaging findings without clinical correlation can lead to unnecessary interventions—always correlate radiographic changes with symptoms 2